According to General and Oral Pathology for the Dental Hygienist by Leslie Delong and Nancy W. Burkhart, hyperplasia is an increase in the number of cells in a tissue or organ. This results in enlargement of that part. It may also be a result of excessive hormone stimulation, chronic cell injury, or extensive cell death (pg. 35).
In Case #1, this is drug-induced gingival hyperplasia due to the patient using phenytoin for epilepsy. Gingival enlargement is usually caused by the patient taking medications such as phenytoin (Dilantin), calcium channel blockers, and cyclosporine. Other underlying factors present are bacterial plaque and calculus. The free gingiva is generalized pink with localized erythematous. The tissue looked edematous clinically; however, the tissue was firm when palpated. There are many etiologies that cause gingival enlargement in this case once we review the medical history we see that this case is a drug-induced gingival enlargement. As the tissue grows it become difficult to control plaque growth and the tissue becomes erythmatic or cyanotic and bleed easily. Histopathology: Hyperplasia of connective tissue and epithelium. Acanthosis of the epithelium is seen with elongated rete pegs extended deep into the connective tissue.
MRS. CASE # 1
Medical History Review:
Patient states:
Orthodontic treatment from 1995-1998
Breathing problems: difficulty breathing during seizures
Visual impairment: wears glasses since 2004
Recurrent neck pain: after seizures
Injury to head, neck, teeth: injury occurs during grand mal seizures
Fainting spells or loss of consciousness
Seizures- grand mal
Numbness or paralysis: after seizures
Muscle weakness: after seizures
Problem w/walking, balance, dizziness: after seizures
Recent or recurrent headaches
Depression: not diagnosed
Childhood vaccinations: completed 2004
Hep B vaccination: completed 2004
Flu vaccine: 2009
Prior to treatment the class of 2011 will send out a medical consult in order to ensure that the patient is safe for treatment.
Mrs. Case current medication:
Upon thorough review of Mrs. Case medical history and medical consult. Her periodontal assessments are as follows:
After gathering all the assessments for Mrs. Case # 1 the DDS exam revealed: Distal occlusal decay on tooth # 14, mesial, occlusal and distal decay on tooth # 22. A thorough explanation was provided to Mrs. Case including showing the patient what areas have decay in order for the patient to have a good understanding. A referral was provided to the patient in order for her to take to her attending dentist in order to get the work done. Patient understands the importance of getting these areas treated.
RADIOGRAPHIC EVALUATION:
Missing teeth: #1,5,12,16,17,21,28,32: extracted for orthodontic treatment
Trabecular pattern is consistent with no radiolucencies or radiopacities noted.
Lamina dura is intact.
Alveolar crest is generalized1-2 mm away from CEJ, with localized 3-4 on # 7.
PDL is widened on #6, #12, and #23-#26 due to occlusion.
Areas of decay: #13 distal, #14 distal-occlusal decay, #22: mesial-occlusal-distal decay
After a thorough explanation of the radiographs and the findings that we have. Critical thinking form is gone over explaining what we want to see from the treatment that we are providing as well as how we are going to work with the patient in order to get her to healthier oral health.
The treatment plan was presented to the instructor. Then to the patient explaining the use of the anesthesia as well as the chlorohexidine rinse for the deep pockets. A description of the disease progress is presented to the patient in order for her to understand what is going on and ways to improve at home care. Appointment # 1:
S: Patient here for re-care appointment and is concerned about her tender gums
O: RMH, BP:115/68, P:65, R:16, E and I, no findings. Reviewed brushing with patient. Went over the bass technique making sure that the patient is holding toothbrush at a 45 degree angle to the gingiva to ensure that she stimulates the hyperplasia of the the gingiva.
A: ASA II
P: Gather assessments, x-ray check, DDS exam- referral for # 13 distal decay, # 14 occlusodistal decay, # 22 mesial occlusal distal decay, chip on tooth # 3.
NV: Second check in............................... MVC Class 2011
Appointment # 2 S: Patient is here for a re-care appointment and is concerned about her tender gumsO: RMH, BP:115/68, P:65, R:16, Extra-oral findings- enlarged left submandibular gland asymptomatic, enlargement of the upper and low lips. TMD findings- none. Intra-oral- generalized gingival hyperplasia, slight mandibular tori. Salivary flow- adequate.Maximum opening- 55 mm. Gingival description: Free- generalized pink with localized erythematous, edematous, bulbous, and shiny. Attached- generalized pink with localized erythematous, spongy and shiny. MBI- 23% Probing depths- generalized 4-5 with localized 2-3. Recession- none-noted. Fremitus- + # 6-11. Furcations- none noted. Mobility- + 6-11, 23-26 associated with patients occlusion. Angle's Classification- Class I with 4mm overjet bilaterally, # 6 occludes directly over # 27. Facial profile- mesognathic. PI-15%. Missing teeth #1,5,12,16,17,21,28,32. Amlg #2 O, Amlg #3 O, #7 RCT w porcelain crown, Amlg #14 O, Amlg #15 O, Amlg #18 O, Amlg #19 DO, Amlg #20 O, Amlg #29 O, Amlg # 30 O, Amlg #31 O. Area of decay #13 D, #14 DO, #22 MOD, Watch # 3. Quality of radiographs is diagnostic. Trabecular pattern is consistent with no radiolucencies or radiopacities noted. Lamina dura is intact, Alveolar process is generalized1-2 mm away from CEJ, with localized 3-4 on # 7. PDL is widened on #6, #12, and #23-#26 due to force on these teeth when patient occludes.A: ASA II, ADA II, AAP- generalized slight chronic periodontitis due to plaque and calculus modified by systemic illness.P: Second check in, PI, OHINV: Scale URQ, LRQ with anesthesia, CHX irrigation, OHI................................MVC Class of 2011
Appointment # 3S: Patient here for recare appointment and is concerned about her tender gumsO: RMH, BP:115/68, P:65, R:16, E and I, no findings. A: ASA II, ADA II, AAP- generalized slight chronic periodontitis due to plaque and calculus modified by systemic illness.
P: Scaled URQ, LRQ with anesthesia using 2 % lidocaine with vasopressor for a total amount of 5.4 ml. Administered PSA, GP, AMSA, IA, Buccal on patients right side. Patient tolerated the procedure well and left clinic in good condition. Irrigated posterior pockets with CHX rinse, instructed patient to not eat or drink for 30 minutes after procedure.
NV: OHI, Scale ULQ, LLQ, CHX irrigation, apply fluoride varnish................................MVC Class of 2011
Appointment # 4
S: Patient is here for recare appointment and is concerned about her tender gums.
O: RMH, BP: 116/65, P:66, R: 17, E & I, no findings.
A: ASA II, ADA II, AAP- generalized slight chronic periodontitis due to plaque and calculus modified by systemic illness.
P: Scaled LLQ, ULQ with anesthesia using 2% lidocaine with vasopressor for a total amount of 5.4 ml. Administered IA/Buccal, PSA, GP, AMSA, on patient's left side. Patient tolerated the procedure well and left clinic in good condition. Irrigated posterior pockets with CHX rinse, instructed patient to not eat of drink for 30 minutes after procedure.
NV: 3 month recare...................................................MVC Class of 2011 Comments from Ms. Lesser: This is an interesting presentation of a case. I would ask you this question - could you scroll through this page and have it make any sense to you? Cases should have a logical progression that is equivalent to what one would do when he/she is treating a patient. In addition to having a logical progression, there should be explanations incorporated into the case to explain the events that have occurred including the outcomes to the readers. Items that are missing include: 1) explanations; 2) prognosis; 3) references to present the concepts that should be presented during this case; and 4) reference page to present the references. I will place the class grade in your mailboxes tomorrow. Please look over the grading rubric; it is very explicit to what is being evaluated. The rubrics are uploaded on WebCT for you convenience.
Case #1 - Hyperplasia
According to General and Oral Pathology for the Dental Hygienist by Leslie Delong and Nancy W. Burkhart, hyperplasia is an increase in the number of cells in a tissue or organ. This results in enlargement of that part. It may also be a result of excessive hormone stimulation, chronic cell injury, or extensive cell death (pg. 35).
In Case #1, this is drug-induced gingival hyperplasia due to the patient using phenytoin for epilepsy. Gingival enlargement is usually caused by the patient taking medications such as phenytoin (Dilantin), calcium channel blockers, and cyclosporine. Other underlying factors present are bacterial plaque and calculus. The free gingiva is generalized pink with localized erythematous. The tissue looked edematous clinically; however, the tissue was firm when palpated. There are many etiologies that cause gingival enlargement in this case once we review the medical history we see that this case is a drug-induced gingival enlargement. As the tissue grows it become difficult to control plaque growth and the tissue becomes erythmatic or cyanotic and bleed easily. Histopathology: Hyperplasia of connective tissue and epithelium. Acanthosis of the epithelium is seen with elongated rete pegs extended deep into the connective tissue.
MRS. CASE # 1
Medical History Review:
Patient states:
Orthodontic treatment from 1995-1998
Breathing problems: difficulty breathing during seizures
Visual impairment: wears glasses since 2004
Recurrent neck pain: after seizures
Injury to head, neck, teeth: injury occurs during grand mal seizures
Fainting spells or loss of consciousness
Seizures- grand mal
Numbness or paralysis: after seizures
Muscle weakness: after seizures
Problem w/walking, balance, dizziness: after seizures
Recent or recurrent headaches
Depression: not diagnosed
Childhood vaccinations: completed 2004
Hep B vaccination: completed 2004
Flu vaccine: 2009
Prior to treatment the class of 2011 will send out a medical consult in order to ensure that the patient is safe for treatment.
Mrs. Case current medication:
Upon thorough review of Mrs. Case medical history and medical consult. Her periodontal assessments are as follows:
After gathering all the assessments for Mrs. Case # 1 the DDS exam revealed: Distal occlusal decay on tooth # 14, mesial, occlusal and distal decay on tooth # 22. A thorough explanation was provided to Mrs. Case including showing the patient what areas have decay in order for the patient to have a good understanding. A referral was provided to the patient in order for her to take to her attending dentist in order to get the work done. Patient understands the importance of getting these areas treated.
RADIOGRAPHIC EVALUATION:
Missing teeth: #1,5,12,16,17,21,28,32: extracted for orthodontic treatment
Restorations: #2: occlusal amalgam, #3 occlusal amalgam, #7: root canal with porcelain crown, #14: occlusal amalgam, #15: occlusal amalgam, #18 occlusal amalgam, #19 distal-occlusal amalgam, #20: occlusal amalgam, #29: occlusal amalgam, #30: occlusal amalgam, #31: occlusal amalgam.
Quality of radiographs is diagnostic.
Trabecular pattern is consistent with no radiolucencies or radiopacities noted.
Lamina dura is intact.
Alveolar crest is generalized1-2 mm away from CEJ, with localized 3-4 on # 7.
PDL is widened on #6, #12, and #23-#26 due to occlusion.
Areas of decay: #13 distal, #14 distal-occlusal decay, #22: mesial-occlusal-distal decay
After a thorough explanation of the radiographs and the findings that we have. Critical thinking form is gone over explaining what we want to see from the treatment that we are providing as well as how we are going to work with the patient in order to get her to healthier oral health.
The treatment plan was presented to the instructor. Then to the patient explaining the use of the anesthesia as well as the chlorohexidine rinse for the deep pockets. A description of the disease progress is presented to the patient in order for her to understand what is going on and ways to improve at home care.
Appointment # 1:
S: Patient here for re-care appointment and is concerned about her tender gums
O: RMH, BP:115/68, P:65, R:16, E and I, no findings. Reviewed brushing with patient. Went over the bass technique making sure that the patient is holding toothbrush at a 45 degree angle to the gingiva to ensure that she stimulates the hyperplasia of the the gingiva.
A: ASA II
P: Gather assessments, x-ray check, DDS exam- referral for # 13 distal decay, # 14 occlusodistal decay, # 22 mesial occlusal distal decay, chip on tooth # 3.
NV: Second check in............................... MVC Class 2011
Appointment # 2
S: Patient is here for a re-care appointment and is concerned about her tender gumsO: RMH, BP:115/68, P:65, R:16, Extra-oral findings- enlarged left submandibular gland asymptomatic, enlargement of the upper and low lips. TMD findings- none. Intra-oral- generalized gingival hyperplasia, slight mandibular tori. Salivary flow- adequate.Maximum opening- 55 mm. Gingival description: Free- generalized pink with localized erythematous, edematous, bulbous, and shiny. Attached- generalized pink with localized erythematous, spongy and shiny. MBI- 23% Probing depths- generalized 4-5 with localized 2-3. Recession- none-noted. Fremitus- + # 6-11. Furcations- none noted. Mobility- + 6-11, 23-26 associated with patients occlusion. Angle's Classification- Class I with 4mm overjet bilaterally, # 6 occludes directly over # 27. Facial profile- mesognathic. PI-15%. Missing teeth #1,5,12,16,17,21,28,32. Amlg #2 O, Amlg #3 O, #7 RCT w porcelain crown, Amlg #14 O, Amlg #15 O, Amlg #18 O, Amlg #19 DO, Amlg #20 O, Amlg #29 O, Amlg # 30 O, Amlg #31 O. Area of decay #13 D, #14 DO, #22 MOD, Watch # 3. Quality of radiographs is diagnostic. Trabecular pattern is consistent with no radiolucencies or radiopacities noted. Lamina dura is intact, Alveolar process is generalized1-2 mm away from CEJ, with localized 3-4 on # 7. PDL is widened on #6, #12, and #23-#26 due to force on these teeth when patient occludes.A: ASA II, ADA II, AAP- generalized slight chronic periodontitis due to plaque and calculus modified by systemic illness.P: Second check in, PI, OHINV: Scale URQ, LRQ with anesthesia, CHX irrigation, OHI................................MVC Class of 2011
Appointment # 3S: Patient here for recare appointment and is concerned about her tender gumsO: RMH, BP:115/68, P:65, R:16, E and I, no findings.
A: ASA II, ADA II, AAP- generalized slight chronic periodontitis due to plaque and calculus modified by systemic illness.
P: Scaled URQ, LRQ with anesthesia using 2 % lidocaine with vasopressor for a total amount of 5.4 ml. Administered PSA, GP, AMSA, IA, Buccal on patients right side. Patient tolerated the procedure well and left clinic in good condition. Irrigated posterior pockets with CHX rinse, instructed patient to not eat or drink for 30 minutes after procedure.
NV: OHI, Scale ULQ, LLQ, CHX irrigation, apply fluoride varnish................................MVC Class of 2011
Appointment # 4
S: Patient is here for recare appointment and is concerned about her tender gums.
O: RMH, BP: 116/65, P:66, R: 17, E & I, no findings.
A: ASA II, ADA II, AAP- generalized slight chronic periodontitis due to plaque and calculus modified by systemic illness.
P: Scaled LLQ, ULQ with anesthesia using 2% lidocaine with vasopressor for a total amount of 5.4 ml. Administered IA/Buccal, PSA, GP, AMSA, on patient's left side. Patient tolerated the procedure well and left clinic in good condition. Irrigated posterior pockets with CHX rinse, instructed patient to not eat of drink for 30 minutes after procedure.
NV: 3 month recare...................................................MVC Class of 2011
Comments from Ms. Lesser:
This is an interesting presentation of a case. I would ask you this question - could you scroll through this page and have it make any sense to you? Cases should have a logical progression that is equivalent to what one would do when he/she is treating a patient. In addition to having a logical progression, there should be explanations incorporated into the case to explain the events that have occurred including the outcomes to the readers. Items that are missing include: 1) explanations; 2) prognosis; 3) references to present the concepts that should be presented during this case; and 4) reference page to present the references.
I will place the class grade in your mailboxes tomorrow. Please look over the grading rubric; it is very explicit to what is being evaluated. The rubrics are uploaded on WebCT for you convenience.